Publications by authors named "Dimitri A Parra"

28 Publications

  • Page 1 of 1

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series.

Pediatr Radiol 2021 Jan 30. Epub 2021 Jan 30.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality.

Objective: To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children.

Materials And Methods: We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg.

Results: Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease.

Conclusion: Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.
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http://dx.doi.org/10.1007/s00247-020-04928-2DOI Listing
January 2021

Findings encountered in percutaneous cholangiography in a case of post-transplant recurrence of hepatic Langerhans cell histiocytosis with biliary involvement.

Pediatr Transplant 2020 Sep 28:e13838. Epub 2020 Sep 28.

Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.

This case report describes a four-year-old boy who presented with the diagnosis of LCH with liver involvement. This required a living-related liver transplant one year later. The primary disease recurred in the transplanted liver 6 months post-transplant and led to progressive biliary dilatation. A percutaneous trans-hepatic cholangiogram was performed five years after transplant, showing a pattern of multifocal biliary duct strictures mimicking the pattern of primary sclerosing cholangitis and a stenosis of the biliary-enteric anastomosis. Despite management with an internal-external biliary drain, the stenosis of the biliary-enteric anastomosis evolved to an occlusion one year after drain removal. This was associated with progression of the changes in the biliary tree, this time associated with significant saccular dilatations secondary to the multiple areas of stenosis. Due to these findings and progressive deterioration of the function of the graft, the patient required re-transplantation. This report illustrates the findings in imaging of the biliary tree secondary to the recurrence of LCH after liver transplantation, which may help to recognize this complication to physicians facing a similar clinical scenario.
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http://dx.doi.org/10.1111/petr.13838DOI Listing
September 2020

Use of drug-coated balloons in the management of a recalcitrant postsurgical hepatic vein stenosis in a pediatric patient.

Radiol Case Rep 2020 Oct 11;15(10):1864-1869. Epub 2020 Aug 11.

Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

Drug-coated balloons (DCB) are a treatment alternative to conventional angioplasty in arterial, hemodialysis fistulas, and venous stenoses. This case report describes a child with the diagnosis of hepatoblastoma treated with chemotherapy and a right extended hepatectomy with venous reconstruction. The patient presented with signs and symptoms of portal hypertension due to a hepatic venous outflow obstruction secondary to stenosis of the surgical anastomosis. The response to conventional angioplasty was limited with frequent recurrence of symptoms. DCBs were used as an alternative prior to stent consideration aiming to assess if these devices could provide improvement of the symptoms and as a long-term therapy. The use of DCBs increased the time interval of reinterventions in comparison with conventional angioplasty. The patient eventually required stents due to recurrence of the primary disease. While this report does not provide an in-depth evaluation in terms of the efficacy and safety of DCB, this case illustrates a potential novel treatment modality to be considered for children, when stenotic venous lesions not amenable for stenting are present.
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http://dx.doi.org/10.1016/j.radcr.2020.07.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426328PMC
October 2020

Acute Budd-Chiari syndrome during hepatic vein catheterization.

Radiol Case Rep 2020 Oct 11;15(10):1853-1857. Epub 2020 Aug 11.

Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

This case report describes a 4-year-old male with a history of hepatoblastoma, treated with chemotherapy followed by a right extended hepatectomy. Secondary to this, the patient experienced recurrent hepatic vein stenosis. He was treated initially with conventional angioplasty, followed by paclitaxel-coated balloon dilatations in an attempt to prevent episodes of re-stenosis. During the catheterization of the hepatic vein in one of the treatments, hemodynamic instability due to an acute Budd-Chiari syndrome occurred. The hemodynamic compromise became unresponsive to intravascular resuscitation and inotropic support. The patient was then treated with an emergency conventional angioplasty of the hepatic vein, which resulted in a rapid response and eventually in a full recovery. The etiology of this complication remains unclear; however, it may have been secondary to endothelial damage leading to acute thrombosis and/or venous spasm. Conventional angioplasty was successful in managing this complication. Awareness of iatrogenic acute Budd-Chiari syndrome as a potentially fatal complication during hepatic catheterization/dilatation, especially in the posthepatectomy setting, successful management of this complication, and the importance of a multidisciplinary and rapid response, is emphasized.
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http://dx.doi.org/10.1016/j.radcr.2020.07.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426323PMC
October 2020

The utility of post-biopsy ultrasonography in detecting complications after percutaneous liver biopsy in children.

Pediatr Radiol 2020 11 13;50(12):1717-1723. Epub 2020 Aug 13.

Department of Medical Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Surveillance post image-guided percutaneous liver biopsy in children is variable.

Objective: The aim of this study was to assess the value of 4-6-h post-procedure ultrasonography (US) in detecting post-liver-biopsy hemorrhage.

Materials And Methods: This prospective study included pediatric patients who underwent US-guided percutaneous liver biopsies. All children had a US study obtained pre-procedure and one obtained 4-6 h post-procedure; US examinations were deemed positive if abnormalities were present. We also reviewed any subsequent imaging that was performed within 7 days (late imaging) at the discretion of the referring team. Changes in US findings (ΔUS) were graded by two radiologists using a descriptive non-validated scale (none, minimal, marked). Hemoglobin (Hb) levels were assessed pre-procedure and 4 h post-procedure. The diagnostic accuracy of US changes for detecting post-procedural hemorrhage was calculated based on a drop in Hb >1.5 g/dL or Hb >15% from baseline (ΔHb). We used a Kruskal-Wallis test to correlate the ΔHb with ΔUS. Association between late-imaging and post-procedure US findings was tested using a chi-square test. We included 224 biopsies.

Results: The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of post-procedure US in detecting post-procedure hemorrhage ranged 26.3-42.1%, 72.4-93.3%, 0.22-0.42, and 0.87-0.88, respectively. No significant association was seen between the ΔHb and sonographic findings (P=0.068). No significant difference was seen in the need for late imaging between children who did and those who did not have positive US findings (P=0.814).

Conclusion: The sensitivity and PPV of post-procedure US in detecting post-procedural hemorrhage are low. Our findings do not support routine post-procedure surveillance US.
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http://dx.doi.org/10.1007/s00247-020-04783-1DOI Listing
November 2020

Image guided sacroiliac joint corticosteroid injections in children: an 18-year single-center retrospective study.

Pediatr Rheumatol Online J 2020 Jun 17;18(1):52. Epub 2020 Jun 17.

Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Background: Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/- adjacent tissues). The treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint injections are frequently requested in pediatric patients with sacroiliitis. The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis.

Methods: A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid injections (2000-2018). Clinical information was collected from Electronic Patient Charts and procedural details from PACS. Efficacy was determined clinically, by MRI, or both when available.

Results: 50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy (54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47% escalated treatment.

Conclusion: Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and imaging improvement, requiring long-term maintenance or escalation of medical treatment.
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http://dx.doi.org/10.1186/s12969-020-00435-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301971PMC
June 2020

Embolization of congenital portosystemic shunt presenting after pediatric liver transplantation: Case report and literature review.

Pediatr Transplant 2020 08 14;24(5):e13713. Epub 2020 May 14.

Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

This case report describes a 13-year 10-month-old girl who underwent a deceased-donor split LT for primary diagnosis of biliary atresia at the age of 12 months, who presented with a lower GI bleed. Ultrasound and CT revealed a venous vascular anomaly involving the cecum and ascending colon, with communication of the SMV and pelvic veins consistent with a CEPS. Associated varices were noted in the pelvis along the uterus and urinary bladder. These findings were confirmed by trans-hepatic porto-venography, which was diagnostic and therapeutic as a successful embolization of the CEPS was performed using micro-coils. There were no complications following the procedure and no further GI bleeding occurred, illustrating the efficacy of this treatment option for CEPS. We discuss the literature regarding the presenting complaint of GI bleeding post-LT, CEPS as a rare cause of GI bleeding and its association with PV, and the classification and treatment of CEPS.
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http://dx.doi.org/10.1111/petr.13713DOI Listing
August 2020

Percutaneous removal of biliary stones post-liver transplant in a pediatric patient: Case report and review of the literature.

Pediatr Transplant 2020 06 23;24(4):e13715. Epub 2020 Apr 23.

Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

This case report describes an 8-year-old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary-enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%-90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary-enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal-external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non-transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients.
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http://dx.doi.org/10.1111/petr.13715DOI Listing
June 2020

Ultrasound-guided techniques for peripheral intravenous placement in children with difficult venous access.

Paediatr Anaesth 2020 02 19;30(2):108-115. Epub 2019 Dec 19.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada.

Peripheral intravenous placement in children can be challenging. Different techniques have been used to improve first pass success rates in children with known history of difficult venous access including surface landmarking, local warming, transillumination, ultrasonography, epidermal nitroglycerin, central venous access, intraosseous placement, and venous cutdown. Among these, ultrasound guidance has garnered the most interest among anesthesiologists. The cumulative literature surrounding the utility of ultrasound-guided peripheral intravenous placement in children with and without difficult venous access has shown mixed results. Literature on the utility of ultrasound guidance for peripheral intravenous placement in children under deep sedation or anesthesia is limited but encouraging. This review summarizes the overall evidence for ultrasound-guided peripheral intravenous placement in children with difficult venous access under deep sedation or general anesthesia. Furthermore, five subtly varying approaches to ultrasound-guided peripheral intravenous placement with their advantages and disadvantages will be discussed. One of these five approaches is Dynamic Needle Tip Positioning. Utilizing a short axis out of plane ultrasound view, this promising technique allows for accurate needle tip localization and may increase the success rate of peripheral intravenous placement, even in small children, under deep sedation, or general anesthesia.
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http://dx.doi.org/10.1111/pan.13780DOI Listing
February 2020

Evaluation of implanted venous port-a-caths in children with medical complexity and neurologic impairment.

Pediatr Radiol 2019 09 13;49(10):1354-1361. Epub 2019 Jul 13.

Image Guided Therapy Centre, Diagnostic Imaging Department, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication.

Objective: To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access.

Materials And Methods: We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath.

Results: Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1 years; median weight 13.7 kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P<0.001) in numbers of peripheral intravenous attempts, peripheral intravenous starts and skin punctures; and a significant reduction (P<0.05) in need for other devices, number of emergency department visits, emergency department visits resulting in hospital admissions, and total admissions. Adverse events were graded as mild (n=18), moderate (n=6) and severe (n=0).

Conclusion: Port-a-cath placement in children with medical complexity with neurologic impairment significantly reduced all peripheral intravenous attempts, peripheral intravenous starts, skin punctures, total number of emergency department visits, visits culminating in admission, and total number of inpatient admissions. Advantages must be considered against potential port-a-cath-related adverse events.
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http://dx.doi.org/10.1007/s00247-019-04470-wDOI Listing
September 2019

Perforations associated with peripherally inserted central catheters in a neonatal population.

Pediatr Radiol 2018 01 6;48(1):109-119. Epub 2017 Oct 6.

Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Peripherally inserted central catheters (PICCs) are increasingly used in neonates but perforations can result in devastating complications such as pericardial and pleural effusions. Identifying risk factors may guide surveillance and reduce morbidity and mortality.

Objective: To determine the risk factors for PICC perforation in neonates.

Materials And Methods: Retrospective case:control (1:2) study of neonates admitted between 2004-2014. Charts and imaging were reviewed for clinical and therapeutic risk factors.

Results: Among 3,454 PICCs, 15 cases of perforation (incidence 0.4%, 5 pericardial effusions, 10 pleural effusions) were matched to 30 controls, based on gestation and insertion date. Timing of perforations post-insertion was median 4 days for pericardial effusions and 21.5 days for pleural effusions. A risk factor for pericardial effusion was lower weight at PICC insertion compared with controls. There were no statistically significant differences between cases and controls in catheter material, insertion site, PICC size and lumen number. Among upper limb PICCs, pericardial effusions were associated with tip positions more proximal to the heart at insertion (P=0.005) and at perforation (P=0.008), compared with controls. Pleural effusions were associated with tip positions more distal from the heart at perforation (P=0.008). Within 48 h before perforation, high/medium risk infusions included total parenteral nutrition (100% cases vs. 56.7% controls, P=0.002) and vancomycin (60% cases vs. 23.3% controls, P=0.02).

Conclusion: PICC-associated pericardial effusions and pleural effusions are rare but inherent risks and can occur at any time after insertion. Risk factors and etiologies are multifactorial, but PICC tip position may be a modifiable risk factor. To mitigate this risk, we have developed and disseminated guidelines for target PICC positions and routinely do radiographs to monitor PICCs for migration and malposition in our NICU. The increased knowledge of risk profiles from this study has helped focus surveillance efforts and facilitate early recognition and treatment.
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http://dx.doi.org/10.1007/s00247-017-3983-xDOI Listing
January 2018

Technique, Safety, and Yield of Bone Biopsies for Histomorphometry in Children.

J Vasc Interv Radiol 2017 Nov 18;28(11):1577-1583. Epub 2017 Aug 18.

Division of Image Guided Therapy, Diagnostic Imaging, Department of Medical Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada.

Purpose: To evaluate image-guided bone biopsy for bone histomorphometry to assess osteoporosis in children with respect to safety and yield.

Materials And Methods: A single-center retrospective review was performed of 79 bone biopsies in 73 patients performed between 2007 and 2015. Biopsies of the iliac bone were performed under general anesthesia, after tetracycline labeling, using a Rochester needle (Medical Innovations International, Inc, Rochester, Minnesota). Ultrasound and fluoroscopic guidance were used in all procedures. Biopsy technique, technical success, safety, and histomorphometry results (complete, incomplete, none) were analyzed.

Results: There were 41 male patients (51.8%). Technical success was achieved in 76/79 (96%) procedures. Of 79 biopsies, 75 (95%) were uneventful. Unplanned overnight observation was required in 3 (minor SIR grade B), and prolonged hospital stay owing to hematoma causing nerve compression pain was required in 1 (major SIR grade D). Complete histomorphometric reports were obtained in 69 (87%) procedures, incomplete reports were obtained in 7 (9%), and no reports were obtained in 3(4%). Incomplete reports were insufficient to provide a definitive diagnosis or guide treatment. Histomorphometry impacted subsequent therapy in 69 (87%) biopsies.

Conclusions: Image-guided bone biopsy for osteoporosis using the Rochester needle is a valuable and safe technique for establishing the diagnosis of osteoporosis and directing treatment based on histomorphometry results.
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http://dx.doi.org/10.1016/j.jvir.2017.07.003DOI Listing
November 2017

Ultrasound-guided steroid tendon sheath injections in juvenile idiopathic arthritis: a 10-year single-center retrospective study.

Pediatr Rheumatol Online J 2017 Apr 11;15(1):22. Epub 2017 Apr 11.

Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Background: The aims of this study were to: (a) Identify tendon sheaths most commonly treated with steroid injections in a pediatric patient population with Juvenile Idiopathic Arthritis (JIA); (b) Describe technical aspects of the procedure; (c) Characterize sonographic appearance of tenosynovitis in JIA; (d) Assess agreement between clinical request and sites injected.

Methods: This was a 10 year single-center retrospective study (May 2006-April 2016) of patients with JIA referred by Rheumatology for ultrasound-guided tendon sheath injections. Patient demographics, clinical referral information, sonographic appearance of the tendon sheaths and technical aspects of the procedure were analyzed.

Results: There were 308 procedures of 244 patients (75% female, mean age 9.6 years) who underwent a total of 926 tendon sheath injections. Ankle tendons were most commonly injected (84.9%), specifically the tendon sheaths of tibialis posterior (22.3%), peroneus longus (20%) and brevis (19.7%). The majority of treated sites (91.9%) showed peritendinous fluid and sheath thickening on ultrasound. There were 2 minor intra-procedure complications without sequelae. A good agreement between clinical request and sites injected was observed.

Conclusions: Ultrasound-guided tendon sheath injections with steroids are used frequently to treat patients with JIA. It is a safe intervention with a high technical success rate. The ankle region, specifically the medial compartment, is the site most commonly injected in this group of patients. The most common sonographic finding is peritendinous fluid and sheath thickening. These findings might assist clinicians and radiologists to characterize and more effectively manage tenosynovitis in patients with JIA.
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http://dx.doi.org/10.1186/s12969-017-0155-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387283PMC
April 2017

Pediatric thyroid FNA biopsy: Outcomes and impact on management over 24 years at a tertiary care center.

Cancer Cytopathol 2016 Nov 14;124(11):801-810. Epub 2016 Jul 14.

Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: Thyroid malignancy is rare in young children, although the incidence increases sharply during adolescence. Nodular thyroid disease and thyroid cancer in children differ substantially from those in adults, because the rates of malignancy among children are roughly 5-fold higher, and local and distant metastases as well as recurrences are more common. Even with the recent introduction of pediatric guidelines, there remains a paucity of pediatric data on which to base clinical decision making. The objectives of this study were to characterize the outcomes of fine-needle aspiration biopsy (FNAB) of nodular thyroid disease at a pediatric tertiary-care institution over a 24-year period and to relate cytopathology to histopathology and management decisions in this population.

Methods: A retrospective review of patients who underwent preoperative FNAB and thyroid surgery between 1992 and 2015 was conducted. In total, 207 nodules were biopsied among 178 patients.

Results: Adequate FNAB samples were obtained in 74% of biopsies. Sixty-five patients underwent thyroidectomy after FNAB. In this group, the malignancy rates for lesions deemed benign, atypical, suspicious, and malignant on FNAB cytology were 16%, 67%, 71%, and 100%, respectively. Twenty-seven individuals underwent >1 biopsy; however, no malignancies were identified in these patients. Surprisingly, the rate of malignancy in patients who underwent preoperative FNAB was not significantly different from the rate in those who proceeded directly to surgery (n = 146).

Conclusions: FNAB remains a valuable tool for preoperative assessment of pediatric thyroid nodules. When samples are adequate for assessment, cytology other than clearly "benign" merits referral for diagnostic or therapeutic thyroidectomy. In this series, FNAB did not reduce rates of surgery for benign disease. Cancer Cytopathol 2016;124:801-10. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncy.21750DOI Listing
November 2016

Variables decreasing tip movement of peripherally inserted central catheters in pediatric patients.

Pediatr Radiol 2016 Oct 7;46(11):1532-8. Epub 2016 Jun 7.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: The position of the tip of a peripherally inserted central catheter (PICC) is crucial; malposition can lead to malfunction of the line or life-threatening events (e.g., arrhythmias, perforation).

Objective: To determine what factors other than arm position and accessed vein might influence the tip position of a PICC.

Materials And Methods: Inclusion criteria were upper limb PICC placement, body weight <20 kg, intraoperative imaging with the arm in 0°, 45° and 90° abduction and an arm view marking the skin entry site relative to the shoulder. Evaluated variables included patient demographics, and PICC and insertion site characteristics. We measured central tip movement in rib units.

Results: We included 112 children who received a PICC (42 girls/70 boys, mean age 31±13 months, mean weight 6.5±4.9 kg). The overall range of central tip movement was -1 to +4 rib units (mean +0.8±0.7 rib units). Silicone PICCs moved significantly less than polyurethane PICCs (P<0.05). PICCs placed in the cephalic vein moved significantly less than those placed in other veins (P<0.05). Patient demographics and PICC characteristics (size, number of lumens, left or right arm accessed, length of the line) did not influence the range of central tip movement of a PICC (P>0.05).

Conclusion: Silicone PICCs and PICCs inserted into the cephalic vein move less than PICCs made of polyurethane and PICCs inserted into the brachial and basilic veins. These findings might assist operators in deciding which PICC to place in children in a given clinical context.
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http://dx.doi.org/10.1007/s00247-016-3648-1DOI Listing
October 2016

Peritonitis following percutaneous gastrostomy tube insertions in children.

Pediatr Radiol 2016 Sep 12;46(10):1444-50. Epub 2016 May 12.

Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.

Background: Percutaneous retrograde gastrostomy has a high success rate, low morbidity, and can be performed under different levels of sedation or local anesthesia in children. Despite its favourable safety profile, major complications can occur. Few studies have examined peritonitis following percutaneous retrograde gastrostomy in children.

Objective: To identify potential risk factors and variables influencing the development and early diagnosis of peritonitis following percutaneous retrograde gastrostomy.

Materials And Methods: We conducted a retrospective case-control study of children who developed peritonitis within 7 days of percutaneous retrograde gastrostomy between 2003 and 2012. From the 1,504 patients who underwent percutaneous retrograde gastrostomy, patients who developed peritonitis (group 1) were matched by closest date of procedure to those without peritonitis (group 2). Peritonitis was defined according to recognized clinical criteria. Demographic, clinical, procedural, management and outcomes data were collected.

Results: Thirty-eight of 1,504 children (2.5%; 95% confidence interval, 1.8-3.5) who underwent percutaneous retrograde gastrostomy developed peritonitis ≤7 days post procedure (group 1). Fever (89%), irritability (63%) and abdominal pain (55%) occurred on presentation of peritonitis. Group 1 patients were all treated with antibiotics; 41% underwent additional interventions: tube readjustments (8%), aspiration of pneumoperitoneum (23%), laparotomy (10%) and intensive care unit admission (10%). In group 1, enteral feeds started on average 3 days later and patients were discharged 5 days later than patients in group 2. There were two deaths not directly related to peritonitis. Neither age, gender, weight, underlying diagnoses nor operator was identified as a risk factor.

Conclusion: Peritonitis following percutaneous retrograde gastrostomy in children occurs in approximately 2.5% of cases. No risk factors for its development were identified. Medical management is usually sufficient for a good outcome. Patients with peritonitis are delayed starting feeds and have a hospital stay that is an average of 5 days longer than those without.
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http://dx.doi.org/10.1007/s00247-016-3628-5DOI Listing
September 2016

IR Approaches to Difficult Removals of Totally Implanted Venous Access Port Catheters in Children: A Single-Center Experience.

J Vasc Interv Radiol 2016 Jun 19;27(6):876-81. Epub 2016 Apr 19.

Division of Image Guided Therapy, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada. Electronic address:

Purpose: To identify factors associated with adherence of implanted venous access port catheters in children and describe technical strategies for removing "stuck" ports.

Materials And Methods: A retrospective single-center review of port removals was conducted between 2003 and 2012. Cases were identified through radiology reports. Clinical details (eg, demographics, disease, port dwell time, interventional techniques) were obtained through patient charts. Cases were classified as difficult removals if there was documented adherence to soft tissues or vein, or simple removals if no difficulty was recorded. Difficult removals were categorized and graded on increasing invasiveness of techniques required. Successful removal was defined as complete removal of the port catheter. Difficult removals were compared with simple removals for factors associated with difficult removal. Of all removals (N = 1,306), 58 were classified as difficult removals (4%).

Results: Using various techniques, 57 of 58 (98%) adherent port catheters were successfully removed. Factors identified with difficult removals included primary diagnosis of acute lymphoblastic leukemia (ALL) (78% vs 37%, P < .0001), age at insertion (3.7 y vs 5.4 y, P = .0019), and port dwell time (median 1,087 d vs 616 d, P < .0001).

Conclusions: Difficulty removing port catheters in children is uncommon. Port catheters can usually be removed successfully using various IR techniques ranging in invasiveness. There is an association of difficult removal with early age at insertion, ALL diagnosis, and long port dwell time. Awareness of these factors may help physicians inform parents of potential difficulties and plan the removal procedure.
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http://dx.doi.org/10.1016/j.jvir.2016.02.021DOI Listing
June 2016

Evaluation of Radiology Teachers' Performance and Identification of the "Best Teachers" in a Residency Program: Mixed Methodology and Pilot Study of the MEDUC-RX32 Questionnaire.

Acad Radiol 2016 07 6;23(7):779-88. Epub 2016 Apr 6.

Department of Gastroenterology, Pontificia Universidad Católica de Chile, Marcoleta 367 (mailbox 114-D). Santiago, Chile. Electronic address:

Rationale And Objectives: Radiology teachers are well trained in their specialty; however, when working in academic institutions, faculty development and promotion through the education pathway tends to be based on their teaching knowledge and skills. The aim of this study is to assess psychometric properties of the Medicina Universidad Católica-Radiology 32 items (MEDUC-RX32), an instrument designed to evaluate the performance of postgraduate radiology teachers and to identify the best teachers.

Materials And Methods: Mixed methodology was used, including qualitative and quantitative phases. The psychometric properties of the MEDUC-RX32 survey were performed by factor analysis (validity), Cronbach alpha coefficient, and G coefficient (reliability). The residents assessed their teachers and simultaneously voted for the "best teacher," which was used as a gold standard for the receiver operating characteristic curves construction comparing their votes with the global score.

Results: A total of 28 residents answered 164 surveys. The global score was 6.23 ± 0.8 (scale from 1 to 7). The factor analysis showed six domains of the resident's perception: (1) tutorial teaching, feedback, and independent learning; (2) communication and teamwork; (3) learning objectives; (4) respectful behavior; (5) radiological report; and (6) teaching and care support. The tutor's strengths were related with respectful behavior and teamwork. The instrument is highly reliable with a Cronbach alpha of 0.937 and a G coefficient of 0.831 (with a minimum of 8 residents). The MEDUC-RX32 instrument has a sensitivity of 91.7% and specificity of 83.3% to identify tutors as best teachers with at least one vote with an area under the receiver operating characteristic curve of 0.931 with a cutoff of 5.94.

Conclusions: The MEDC-RX32 instrument is a multidimensional, valid, and highly reliable method to evaluate radiology teachers, identifying teachers with excellence in tutorial teaching in a postgraduate radiology program.
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http://dx.doi.org/10.1016/j.acra.2016.02.015DOI Listing
July 2016

Ultrasound-Guided Thrombin Injection for the Treatment of Femoral Pseudoaneurysm in Pediatric Patients.

J Vasc Interv Radiol 2016 Apr;27(4):519-23

Division of Imaging Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, Canada M5G 1X8. Electronic address:

Eight patients with nine femoral pseudoaneurysms were treated with 13 ultrasound-guided thrombin injections. Mean patient age was 3.3 years (range, 5 mo to 13.6 y), mean pseudoaneurysm diameter was 2.0 cm ± 0.6, and mean thrombin dose was 119 IU (500 IU/mL ± 116; 0.95 CI). Mean follow-up was 27 days (range, 7-120 d). Eight pseudoaneurysms were successfully treated, and one failed to close as a result of arterial wall disease. No complications were observed. The approach used at the authors' pediatric institution resulted in safe and effective treatment of femoral pseudoaneurysms.
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http://dx.doi.org/10.1016/j.jvir.2015.12.756DOI Listing
April 2016

Successful Image-Guided Retrieval of an Embolized Fragment of a Fractured Haemodialysis Catheter Tip from the Pulmonary Artery.

Case Rep Nephrol Dial 2016 Jan-Apr;6(1):21-5. Epub 2016 Feb 3.

Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada.

Background: Cuffed, double-lumen, tunneled haemodialysis catheters are a common means of vascular access in paediatric haemodialysis, particularly in infants. Haemodialysis catheter fracture with distal embolization is a rare complication.

Case Report: A 2-year-old boy was receiving chronic haemodialysis via a right internal jugular cuffed, double-lumen, tunneled haemodialysis catheter, inserted 3 months previously. He was asymptomatic and was incidentally found to have had embolization of a fractured catheter tip into a segmental branch of the left pulmonary artery. The catheter was replaced and the embolized fragment successfully retrieved, non-surgically, using an image-guided endovascular approach with a loop snare device.

Conclusion: Haemodialysis catheter fracture with distal embolization is a rare complication in both adults and children and is usually associated with prolonged use and catheter fatigue. Retrieval of the embolized fragment should always be attempted to prevent possible complications. Awareness of this potential complication is important to facilitate diagnosis and management.
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http://dx.doi.org/10.1159/000443728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772621PMC
March 2016

Technical tips to perform safe and effective ultrasound guided steroid joint injections in children.

Authors:
Dimitri A Parra

Pediatr Rheumatol Online J 2015 7;13. Epub 2015 Jan 7.

Pediatric Interventional Radiologists, Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON Canada ; Department of Medical Imaging, University of Toronto, Toronto, Canada.

Background: The aim of this article is to describe the technique used to perform ultrasound guided steroid joint injections in children in a group of joints that can be injected using ultrasound as the only image guidance modality.

Findings: The technique is described and didactic figures are provided to illustrate key technical concepts.

Conclusion: It is very important to be familiar with the sonographic appearance of the pediatric joints and the developing bone when performing ultrasound-guided joint injections in children.
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http://dx.doi.org/10.1186/1546-0096-13-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350981PMC
September 2015

Placement of an internal-external biliary drain through a bilio-enteric fistula in a neonate to re-establish antegrade bile flow after liver transplantation.

Pediatr Transplant 2014 Nov 19;18(7):E236-9. Epub 2014 Aug 19.

Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Three-month-old baby girl with history of post-liver transplant hepatic artery dissection treated with ligation after take down of the biliary anastomosis and placement of a surgical external common bile duct drain. There was persistent malfunction of this drain. A bilio-enteric fistula was noted during the later placement of an image guided percutaneous external drain. Subsequently, an internal-external biliary drain was successfully placed through this fistula. An excellent clinical and functional result was achieved.
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http://dx.doi.org/10.1111/petr.12336DOI Listing
November 2014

Computed tomography angiography in acute gastrointestinal and intra-abdominal bleeding in children: preliminary experience.

Can Assoc Radiol J 2013 Nov 20;64(4):345-50. Epub 2013 Feb 20.

Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Image Guided Therapy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.carj.2012.12.002DOI Listing
November 2013

Use and accuracy of US guidance for image-guided injections of the temporomandibular joints in children with arthritis.

Pediatr Radiol 2010 Sep 4;40(9):1498-504. Epub 2010 Mar 4.

Department of Diagnostic Imaging, Division of Image Guided Therapy, The Hospital for Sick Children, Toronto, Canada.

Background: Juvenile idiopathic arthritis (JIA) has an incidence that ranges from 1 to 22 per 100,000 children worldwide, with involvement of the temporomandibular joint (TMJ) in 17-87% of patients. Intraarticular corticosteroid injections are beneficial in the local treatment of JIA and of other types of arthritis.

Objective: To describe and assess the accuracy of an US-guided technique for visualization of needle placement within the TMJ in children.

Materials And Methods: Between January 2000 and November 2007, 180 TMJ injections were performed during 116 encounters in 83 children with arthritis (71 girls, 12 boys; mean age 12.0 years). Access was obtained under sterile conditions using US guidance (linear 15-MHz or curvilinear 8-MHz transducers) in a coronal plane, and confirmed with CT. To minimize radiation, a limited focused CT protocol was developed.

Results: A bilateral injection was performed in 65 encounters (57%). Twenty-three children had repeat TMJ injections. All injections were performed using US guidance. CT confirmation was used in 127/180 TMJs (70%). In those confirmed with CT, the needle tip was intra-articular in 91% of cases. Triamcinolone hexacetonide was used in 92% of injections and triamcinolone acetonide in 8%. One major complication was encountered (skin atrophy at the injection site).

Conclusion: In our experience, TMJ injections using sonographic guidance is a safe, effective and accurate procedure.
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http://dx.doi.org/10.1007/s00247-010-1581-2DOI Listing
September 2010

Imaging of ambiguous genitalia: classification and diagnostic approach.

Radiographics 2008 Nov-Dec;28(7):1891-904

Department of Diagnostic Imaging, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Disorders of sex development (DSDs) are congenital conditions in which the development of chromosomal, gonadal, or anatomic sex is atypical. DSDs can be classified broadly into four categories on the basis of gonadal histologic features: female pseudohermaphroditism (46,XX with two ovaries); male pseudohermaphroditism (46,XY with two testes); true hermaphroditism (ovotesticular DSD) (both ovarian and testicular tissues); and gonadal dysgenesis, either mixed (a testis and a streak gonad) or pure (bilateral streak gonads). Imaging plays an important role in demonstrating the anatomy and associated anomalies. Ultrasonography is the primary modality for demonstrating internal organs; genitography is used to assess the urethra, vagina, and any fistulas or complex tracts; and magnetic resonance imaging is used as an adjunct modality to assess for internal gonads and genitalia. Early and appropriate gender assignment is necessary for healthy physical and psychologic development of children with ambiguous genitalia. Gender assignment can be facilitated with a team approach that involves a pediatric endocrinologist, geneticist, urologist, psychiatrist, social worker, neonatologist, nurse, and radiologist, allowing timely diagnosis and proper management.
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http://dx.doi.org/10.1148/rg.287085034DOI Listing
January 2009

Normal Doppler spectral waveforms of major pediatric vessels: specific patterns.

Radiographics 2008 May-Jun;28(3):691-706

Department of Diagnostic Imaging, Hospital for Sick Children and University of Toronto, 555 University Ave, Toronto, Ontario, Canada, M5G 1X8.

Every major vessel in the human body has a characteristic flow pattern that is visible in spectral waveforms obtained in that vessel with Doppler ultrasonography (US). Spectral waveforms reflect the physiologic status of the organ supplied by the vessel, as well as the anatomic location of the vessel in relation to the heart. In addition, the waveforms may be affected by age- and development-related hemodynamic differences. For example, adults tend to have higher flow velocities, whereas neonates, particularly those born prematurely, have higher resistance to flow, especially in the cerebral and renal vascular beds. As Doppler US is performed with increasing frequency for vascular evaluation in children, the recognition of normal flow patterns has become imperative. Familiarity with the waveforms characteristic of specific veins and arteries in children is important. In addition, an understanding of the hemodynamic factors involved provides a useful basis for interpreting waveform abnormalities.
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http://dx.doi.org/10.1148/rg.283075095DOI Listing
June 2008

Sonographic diagnosis of intestinal polyps in children.

Pediatr Radiol 2008 Jun 8;38(6):680-4. Epub 2008 Apr 8.

Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Although colonoscopy is the modality of choice for the diagnosis of intestinal polyps, sonography may be the first diagnostic modality in the evaluation of children with this pathology. Graded compression sonography of the small and large bowel may be useful in diagnosing intestinal polyps. A specific diagnosis is possible in many cases as most polyps have a characteristic appearance. Although sonography is not intended to replace endoscopy in the diagnostic work-up of intestinal polyps, it is important for radiologists to be aware of this appearance as they can be the first in making the diagnosis of intestinal polyps using sonography.
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http://dx.doi.org/10.1007/s00247-008-0812-2DOI Listing
June 2008